Provider Demographics
NPI:1639213994
Name:NIERMANN, MICAH PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:PAUL
Last Name:NIERMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 UNIVERSITY AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2507
Mailing Address - Country:US
Mailing Address - Phone:651-291-2848
Mailing Address - Fax:651-602-6885
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-291-2848
Practice Address - Fax:651-602-6885
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17822208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400537804OtherMEDICARE PTAN